The antenatal appointment: physical and psychological assessment of the woman in pregnancy
The skills of the midwife (Figure 21.1) in antenatal care focus on facilitating women to have a safe, positive experience, and enabling the new family to progress better prepared and healthier. The midwife is recognised as the lead professional in providing high-quality personalised care and co-ordinating the woman’s care, using expert judgement and decision making, which should be in tune with her and her family. Women and their partners need to be able to trust the midwife in order to believe that their maternity care will meet their needs and expectations.
The main contact for the midwife with pregnant women is through the antenatal appointment, at regular intervals throughout the pregnancy. The initial booking visit (see Chapter 20) and subsequent visits should focus on ensuring women are physically and mentally prepared for their birth and postnatal period, as well as being in optimum health.
The midwife’s public health role is well recognised, and women are usually receptive to healthy choices messages, including being a resource for healthy eating and exercise, smoking cessation, drug addiction or other lifestyle choices that may adversely affect health and wellbeing. As well as promoting good health, the midwife also recognises women who may be vulnerable because of physical health, mental well being or socioeconomic circumstances. This vulnerability may be life threatening or have a negative impact on them.
Sharing information with the woman will continue throughout the pregnancy, tailored to the woman’s needs, based on previous assessment, including promoting normal birth and breastfeeding, as well as facilitating choice about place of birth and available care options. Choice and risk need to be balanced and the midwife should be able to facilitate the woman’s expectations and how they can be best supported or considered.
Physical assessments, including abdominal examination, provide an opportunity to assess maternal and fetal wellbeing, whilst diagnosing and managing complications, should they arise. As maternity care becomes more complex, collaboration, referral and effective communication with the wider multidisciplinary care team are essential skills for all midwives.
Physical assessments, used to assess how the woman is adjusting to being pregnancy, include:
- General well being and asking about minor disorders
- Abdominal examination
- Temperature, pulse and blood pressure
- Blood tests to include blood group and Rhesus status, screening for HIV status.
Midwifery 2020 (Department of Health 2010) stated that all women need a midwife and some will also need an obstetrician. Most women will encounter a range of professionals such as health visitors, social workers, and GPs, with the midwife acting as liaison to increase continuity of care. The midwife needs to know who is working locally, both other healthcare professionals and voluntary groups who may be able to enhance care, and ensure that expectations and service provision are aligned to support all women.
Midwives are well versed in the advantages of continuity of care and carer and have a responsibly to champion the care provision that best suits local women. When asked about antenatal care, women want to know that they will be cared for with compassion and understanding, and the team looking after them are highly skilled professionals who will enable and facilitate choice and a safe passage through this life-changing event. Better Births (National Maternity Review 2016) also outline the need for the NHS Personal Maternity Care Budget for women to best support their choices, and midwives need to understand how that is managed locally.
Mental wellbeing – the majority of women will have a positive outlook, tempered with anxiety and fear, but within a normal spectrum of mental wellbeing; pregnancy is a time of emotional upheaval and adjustment to changes in lifestyle and relationships; however, for about 20% of women, this life event is affected by mental illness, recognising that severe perinatal mental health is one of the leading causes of maternal death.
The midwife will need to assess the woman’s mood and emotional wellbeing at every opportunity, always being alert to changes in mood, or general wellbeing that may signify the onset of depression or a more serious mental illness.
Women may have pre-existing mental ill health, or a condition may develop or be diagnosed during pregnancy. Depression is the most prevalent illness; around 10 to 14% of mothers may be affected, which is usually mild but it can progress to a severe depressive illness that can impact on the woman and family for years after the birth, including affecting her self-esteem and family relationships.
The role the midwife plays antenatally in preparing women for the possible changes in mental wellbeing are finely balanced between informing women and partners, whilst not causing unnecessary anxiety. The midwife needs to understand the symptoms of mental ill health and to be able to articulate these to the woman and her partner, including:
- Baby blues
- Antenatal and postnatal depression
- Postnatal/ puerperal psychosis.
It is also important to acknowledge the emerging evidence that possibly 10% of new fathers may suffer anxiety and depression.
Midwifery evidence-based practice should be focused on providing seamless continuity of care, leading to better outcomes for women and their families through the whole of the childbearing experience. Antenatal care is a significant time for pregnant women, as much of the care provided will impact on the health and wellbeing of the woman and her baby; it will also impact on a partner and the wider family, making it a critical life event. Public health opportunities abound during antenatal care, which creates an ideal environment to enhance the health and well being of the entire family, providing messages and support are delivered in a positive and supportive manner to enable the mother to consider her lifestyle choices, and how they may be improved.